Let’s delve into the Medicare Calendar Year 2024 Inpatient Prospective Payment System (IPPS), including its Promoting Interoperability (PI) and quality measure (CQM/eCQM) reporting requirements. For reporting CQMs and eCQMs, the Hospital Inpatient Quality Reporting Program (IQR) is combined with PI. Quality data is uploaded through the Hospital Quality Reporting (HQR) website.
Since most hospitals in the US also participate in the Joint Commission ORYX(r) program, we’ll cover those as well. As we navigate through the intricacies of healthcare CQM reporting, let’s break down the key components:
1. Quality Measure Reporting Requirements:
- eCQMs (Electronic Clinical Quality Measures): Hospitals are required to submit six eCQMs—three mandatory measures and three self-selected measures.
- Hybrid Measures: Hospitals must submit two hybrid measures.
- Process Measures: Submission of two process measures is mandatory.
- Structural Measures: Hospitals need to submit two structural measures.
- Data Accuracy and Completeness Acknowledgement (DACA): Completion of DACA is essential.
- Influenza Immunization Healthcare-Associated Infection (HAI) Measure: Submission of this measure is part of the requirements.
2. EHR Resilience Self-Assessment:
- Starting in CY 2024, hospitals must attest to conducting an annual self-assessment of all 9 Safety Assurance Factors for EHR Resilience (SAFER) Guides during the calendar year in which the EHR reporting period occurs.
3. Active Engagement with CDC’s NHSN:
- To obtain credit for calendar year 2024, eligible hospitals and CAHs must attest to being in active engagement with CDC’s National Healthcare Safety Network (NHSN) to submit Antimicrobial Use and Resistance (AUR) data for the EHR reporting period or claim an applicable exclusion.
eCQM Reporting
The FY 2024 IPPS Final Rule has some changes. Now six (increased from four) eCQMs are required — three mandatory measures and three self-selected measures must be submitted annually.
| Short Name | Measure Name | CMS # | TJC Measure |
|---|---|---|---|
| OPI-1 | Required: Safe Use of Opiods – Concurrent Prescribing | CMS506v6 | Yes |
| PC-02 | Required: Cesarean Birth | CMS334v5 | Yes |
| PC-07 | Required: Severe Obstetric Complications | CMS1028v2 | Yes |
| HH-01 | Hospital Harm – Severe Hypoglycemia | CMS816v3 | Yes |
| HH-02 | Hospital Harm – Severe Hyperglycemia | CMS871v3 | Yes |
| HH-ORAE | New! Hospital Harm – Opioid Related Adverse Effects | CMS819v2 | Yes |
| STK-02 | Discharged on Antithrombotic Therapy | CMS104v12 | Yes |
| STK-03 | Anticoagulation Therapy for Atrial Fibrillation/Flutter | CMS71v13 | Yes |
| STK-05 | Antithrombotic Therapy by the End of Hospital Day Two | CMS72v12 | Yes |
| VTE-1 | Venous Thromboembolisn Prophylaxis | CMS108v12 | Yes |
| VTE-2 | Intensive Care Unit Venous Thromboembolism Prophylaxis | CMS190v12 | Yes |
| GMCS | New! Global Malnutrition Composite Score | CMS986v2 | Yes |
These eCQMs have been discontinued and are not available for 2024:
- PC-05 – Exclusive Breast Milk Feeding measure
- ED-02 – Admit Decision Time to Emergency Department Departure Time for Admitted Patients measure
- STK-02 – Discharged on Statin Medication eCQM
Also, the PC-01 “Elective Delivery” chart-abstracted measure has been retired for 2024.
Hybrid Measures
Hybrid measures combine electronic data with claims data and both are required:
- CMS529v4 – Hybrid HWR – Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data (2024)
- CMS844v4 – Hybrid HWM – Core Clinical Data Elements for the Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure (HWM) (2024)
Process Measures
Two Social Determinants of Health (SDOH) process measures were optional in 2023 and are now required:
- SDOH-1: Screening for Social Drivers of Health. Percent of patients over 18 screened for food, housing, and other SDOH issues.
- SDOH-2: Screen Positive Rate for Social Drivers of Health. Of the patients screened, percent who actually had food, housing, and other SDOH issues.
Hospitals can use a screening method of their choice to implement these measures.
Structural Measures
Two structural measures are also required:
- Maternal Morbidity. If your hospital provides inpatient labor, delivery, and post-partum care, you must attest to whether you have implemented perinatal patient safety practices.
- HCHE: Hospital Commitment to Health Equity. Your hospital must attest to tracking/prioritizing health equity in five domains.
SAFER
The Safety Assurance Factors for EHR Resilience (SAFER) Guides, a set of checklist-based self-assessment tools to improve safety of EHR utilization, were introduced for the 2022 reporting period but at that time, it was OK to attest “No” to having conducted the self-assessment. Beginning with the CY 2024 EHR reporting period, CMS requires eligible hospitals and CAHs to attest ‘‘yes’’ to having conducted an annual self-assessment of all nine SAFER Guides during the EHR reporting period.
Joint Commission ORYX Changes
TJC has worked to align the ORYX reporting requirements with those of IQR. 2024 reporting places a heightened emphasis on outcome measures and, of course, healthcare equity and social determinants of health. The two new eCQMs highlighted in the table, above, have also been added by TJC. As you can see in the table, all eCQMs accepted for IQR are also available for ORYX reporting. Following the lead of IQR, TJC has retired the ED-02 and STK-06 eCQM measures.
There are three eCQMs accepted by TJC but not CMS:
| Short Name | Measure Name | CMS # |
|---|---|---|
| PC-01 | Elective Delivery | CMS113v12 |
| PC-05 | Exclusive Human Milk Feeding | CMS9v12 |
| PC-06 | Unexpected Complications in Term Newborns | CMS851v4 |
Please see TJC website for details.
ONC-Certified Software
Your Third-party Vendor/EHR for reporting 2024 data must be certified for 2015 Edition Cures Update. As in past years, DHIT successfully certified CQMsolution for the 2015 Edition Cures Update for Cypress version 7.2 with all eCQMs and we have been approved as 2024 Qualified Registry. We have taken the lead with certification and our partners are prepared for 2024. If you would like to partner with us for quality measures or as your third-party vendor, please contact us today.
